Introduction

Over 2.5 million people visit pornography websites every 60 seconds [1]. In a recent United States (US) study, 42% of youth between the ages of 10–17 had viewed pornography - with up to 68% of adolescents reporting lifetime exposure to pornography [2]. In the adult US population, up to 11% of males and 3% of females reported feeling like they were addicted to pornography and 1 in 8 males using pornography expressed needing professional help due to compulsive use [3]. With rising internet access and screen time, the prevalence of problematic pornography use (PPU) has also increased [3,4]. The intersection of substance use and behavioral addictions is an emerging area of interest in public health. Among behavioral addictions, specifically addictive digital behaviors, the overconsumption of pornography has become an increasing public health problem [5].

In the literature, PPU is typically defined as an individual’s inability to control the use of pornography, leading to detrimental health consequences [6] such as negative impacts on sexual development in adolescence, difficulty controlling sexual impulses, significant disruptions in one’s personal life (e.g., impact on sexual relationships and psychological health) [1,5]. PPU has also been associated with a higher likelihood of developing anxiety, stress, depression, and suicidal ideation [7]. Although PPU is not clinically recognized as a stand-alone behavioral disorder (in the Diagnostic and Statistical Manual fifth Editions (DSM-5-TR)), it was recently included as one of the impulse control manifestations under the Compulsive Sexual Behaviour Disorder (CSBD) under the 11^th edition of the International Statistical Classification of Diseases and Related Health Problems [8].

In addition, substance use among adolescents and young adults continues to be a public health concern, particularly after the COVID-19 pandemic [9]. Both PPU and substance use (and subsequent substance use disorders) can lead to significant disruptions in daily functioning and overall quality of life [10]. Indeed, PPU may operate similarly to substance use behaviors by stimulating similar pathways in the brain’s reward system, which can lead to dependency and escalating consumption [11]. Thus, substance use in individuals with PPU is an area that warrants further investigation due to the potential for its compounded negative effects. As PPU is frequently associated with impulsivity, dysfunction in mental health, and other psychiatric symptoms [12], these underlying risk factors may exacerbate substance use patterns and potentially, an individual’s treatment outcomes [13]. Notably, several studies indicate CSBD shares core elements with substance use disorders (SUD); and that these core elements may lead to a higher likelihood of developing a SUD or have co-occurring PPU [14]. Although associations between CSBD and substance use have been reported, a review on the association between substance use and PPU remains absent.

By summarizing and characterizing substance use patterns in PPU individuals, the findings from this review can inform the development of effective treatment approaches to reduce the prevalence and impact of PPU and SUDs, especially for vulnerable adolescent populations. Hence, the objective of this scoping review is to examine substance use patterns and associations among individuals with PPU or chronic pornography use, hereafter referred to as PPU. Notably, given the early stage of this research and clinical attention, this scoping review will also capture the different operationalizations of PPU in the existing literature.

Materials and methods

For this review, the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) checklist (S1 File) was used. Pilot searches were completed on an iterative basis (to ensure we captured all operationalizations of PPU) starting early 2024 and the final search terms were finalized in December 2024. This included peer-reviewed, empirical studies published on and before December 4, 2024. Included studies focused on substance use for individuals reporting any type of problematic pornography use or chronic pornography use and the Center for Disease and Control (CDC)’s defined substances (see section below).

Protocol and Registration: The following scoping review has been registered to the Open Science Framework (OSF) - https://doi.org/10.17605/OSF.IO/86X34

Problematic Pornography Use (PPU): PPU or compulsive pornography use is characterized by an individual’s inability to control the use of pornography, leading to detrimental health effects [8,15]. Pornography is typically described as content that showcases sexual material with the main goal of sexually arousing or stimulating the viewer. This can encompass various forms such as visual images, videos, texts, or other media (online or printed). Detrimental health effects of PPU can include both mental and physical effects [16]. Effects include anxiety, depression, and low self-esteem. PPU has been reported to alter the brain’s award system and can result in decreased sensitivity to pleasure and dopamine [17]. PPU can negatively impact relationships by reducing intimacy and its overuse has been associated with sexual dysfunction [3]. Although PPU is not officially recognized as a disorder in the DSM-5, it is a manifestation of CSBD, which include compulsive use, loss of control, tolerance, and withdrawal symptoms [18]. Individuals with PPU struggle with co-occurring disorders such as depression, anxiety, and substance misuse [5].

For this scoping review, PPU is differentiated from the DSM-5 Compulsive Sexual Behavior Disorder (CSBD) (ICD-11), which is a persistent pattern of failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior. Although CSBD could include PPU, this review is not examining substance use trends in individuals with only noted CBSD - as CSBD includes a wide range of sexual behaviors; whereas PPU could be considered a subtype of CSBD, focusing solely on the use of pornographic material. In addition, this review is not examining substance use trends in individuals with internet addiction (same reasons as CSBD).

Substance Use: The CDC’s definition of substance use was used, which refers to the consumption of various substances including alcohol, cannabis, hallucinogens, inhalants, opioids (prescription and illegal), sedatives/hypnotics/anxiolytics, stimulants, tobacco (nicotine), and other (unknown substances) [19]. Substance use can also include any method of intake, whether consumed, inhaled, injected, or otherwise absorbed into the body. Types of substance use include alcohol, tobacco (cigarettes, cigars, smokeless tobacco), illicit drugs (heroin, cocaine), cannabis, vaping, and prescription drugs. Substances can be used experimentally, recreationally, for medical purposes, and can also be used problematically (in the case of substance use disorders).

Results

Study selection

After de-duplication, 949 articles were included for initial title and abstract screening. Next, 27 articles were included for full-text screening. After full-text screening, we had a remaining 8 studies included in qualitative synthesis (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. PRISMA flow diagram.

https://doi.org/10.1371/journal.pgph.0004946.g001

Study and participant characteristics

Sample size ranged from 172 to 1272 participants, Table 1. Studied populations were individuals with substance use disorders (n = 3) [12,14,20], adolescent and young adult students (n = 2) [16,21], veterans (n = 2) [22,23] and sexual minorities (n = 1) [18]. The mean age of participant groups ranged from approximately 15–40 years - with standard deviations of less than 10 years. The groups predominantly consisted of male participants (60–86%), with one male-only study of US veterans [23]; and one study with a majority of female undergraduate students [16]. Two studies examined specifically US veterans [22,23]. The origins of studies were diverse, including the United States [12,22,23], Canada [16], Poland [18], Italy [20], India [21], and Germany [14].

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Study characteristics.

https://doi.org/10.1371/journal.pgph.0004946.t001

Type of substance use measured

Substance type varied across studies and included: alcohol [12,14,16,22,23], smoking [21], cocaine [20], substance use disorder [14,23], cannabis use disorder [16], and drug use [14,18] (Table 2). Alcohol was the most frequently studied substance type (5 of 8) [12,14,16,20,22,23]. Alcohol use disorder or dependence (AUD) was measured in two studies.[22,23]. Golder et al. (2024) [14] was the only study that examined polysubstance use and assessed whether the individual used at least one of the following substances: alcohol, cannabis, cocaine, amphetamine, opioids, hallucinogens, ecstasy, benzodiazepines, and ketamines. Lewczuk et al. (2014) [18] was the only study that measured ‘chemsex’ drugs, which included psychoactive substances to prolong, enhance, or sustain sexual activity. This included methamphetamine, mephedrone, GHB/GBL (gamma-hydroxybutyrate/gamma-butyrolactone), or ketamine.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Synthesis of results and measures of substance use.

https://doi.org/10.1371/journal.pgph.0004946.t002

Pornography operationalization and measures

Across the included studies, no consistent or standard definition of PPU was used (Table 3). Although pornography is not considered a stand-alone DSM-5 recognized disorder, the term, 'pornography addiction' was used in several studies. All studies captured PPU through some form of a self-reported questionnaire. The most common definition of PPU was as a behavioral habit leading to negative consequences and distress, often accompanied by control or impulse difficulties. Of the four studies following this definition, two studies [22,23] utilized the Problematic Pornography Use Scale (PPUS), while the other two [12,18] employed the Brief Pornography Screen (BPS). The PPUS is a 12-item instrument that uses a 6-point Likert scale, referencing a previous 12-month time frame. As indicated in the name, the BPS is a shorter version for screening pornography use within the last six months on a 5-item, 3-point Likert scale.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Operationalization of problematic pornography use.

https://doi.org/10.1371/journal.pgph.0004946.t003

Golder et al. (2024) [14] measured pornography use disorder (PUD), characterized as the combination of CSBD and PPU within the last six months, with a short version of the Problematic Pornography Consumption Scale (PPCS-6). It is a 6-item questionnaire with a 7-point Likert scale, where PPU is defined as a cumulative score of 20 or greater, in combination with a CSBD-19 score of 50 or greater. The remaining three studies did not further specify their measured concept of “PPU”. Moreover, the three studies utilized self-designed items [20,21] or adapted items from an internet gaming disorder measurement instrument [14] as part of their questionnaire, attributed to retrieving quantitative PPU scores.

Discussion

This scoping review examined the association between PPU and substance use. Despite an increasing trend of PPU in individuals across the globe, this review identified only 8 studies that directly examined the relationship between substance use and PPU, identifying a notable gap in the literature. This limited number of studies available suggests that the intersection between PPU and substance use remains under studied. A large proportion of the studies (5 studies) examined alcohol and PPU, from which 2 reported a statistically significant correlation [12,22]; and 3 not significant [14,16,23]. Smoking and cocaine use were also reported to be significantly associated with PPU [20,21]. However, in the Golder et al. (2024) study [14], individuals in the control group had unexpectedly statistically significantly higher scores on the PPCS-6 (higher problematic pornography consumption) than individuals with SUD (p = 0.0003). The researchers attributed these results to underreporting due to potential stigma, differences in relationship status, differing treatment response, differing living environments, and underestimation of specific behaviors related to pornography use. Likewise, another study found insignificant correlations with PPU in relation to CUD and sexualized drug use. From these differing results, mechanisms between PPU and substance use may be more complex and differ pending the type of substance use.

Although both substance use and pornography use are both prevalent public health issues with potential negative health impacts, empirical research surrounding PPU is still in its infancy, especially when compared to more established areas of research such as substance use disorders. Due to preliminary findings and limited research studies, the classification of PPU continues to be a challenge. Furthermore, there is currently no standardized measure of what constitutes 'problematic' pornography use and a lack of validated instruments to assess PPU across diverse populations. As observed in this review, existing studies rely on self-report surveys, which can be influenced by shame, guilt, and stigma, which may lead to underreporting of PPU and acknowledgement of having symptoms of PPU.

This scoping review observed that PPUS was the most frequently used scale in the literature [12,22,23]. However, the review found significant variation in the definitions of PPU, including the use of the terms: ‘PUD’, ‘chronic pornography use’, and ‘pornography addiction’. In terms of operationalization, at least 3 different scales were used (i.e., PPCS-6, PPUS, and BPS) to measure PPU - with different diagnostic criteria. Furthermore, the overlap with the operationalizations of IP (IP-CRIT) and CSBD resulted in challenges in interpreting and synthesizing the results across the 8 cross-sectional studies. Indeed, the absence of standardized diagnostic criteria or a best-practice tool in this field hinders the development of a cohesive body of research, which may complicate comparisons across studies.

This scoping review has several implications for research and practice. With the advent of the internet and accessibility to explicit content, the concept of PPU has garnered recent attention. Particularly, in the adolescent population, some studies have indicated that over 90% of young men and a significant proportion of young women regularly view internet pornography and are exposed to pornography at a young age [5]. The 8 cross-sectional studies in this scoping review showed consensus that PPU and substance use often do co-occur, which may suggest that there may be shared underlying mechanisms of addiction, coping strategies, and impulsivity with both behaviors. Both PPU and substance use are associated with negative mental health outcomes, including anxiety, depression, and impaired cognitive function [24]. Given this overlap between PPU and substance use, integrated intervention programs that address both conditions simultaneously could be more effective. Addressing the above gaps warrants ongoing efforts to standardize terminology, classification of PPU, and measurement tools so that researchers can build a robust body of evidence that supports individuals who struggle with both substance use and PPU.

This is the first scoping review to examine the literature on substance use in individuals with PPU. However, the scoping review has several limitations. The review only included 8 cross-sectional studies, which restricted the inferences and conclusions made from the findings. Notably, small sample sizes highly limited the generalizability of the results, and the cross-sectional design did not allow us to examine any causal relationships between PPU and substance use. As mentioned, the variability of how PPU and substance use were captured across studies also contributed to the challenges in cross-comparison and synthesis of the results. Hence, future longitudinal studies should employ are warranted to understand the temporal dynamics and causative factors that link these behaviors.

Conclusions

This scoping review explored the relationship between PPU and substance use. The review included 8 cross-sectional studies, in which both the operationalizations of PPU and results in its associations with substance use, were mixed in assessing the correlation between PPU and substance use. Future research should focus on standardizing the definition of PPU and conduct longitudinal studies to better understand the causal mechanisms between substance use and PPU.

Supporting information